Wednesday, May 12, 2010

Shared Doctor Visits vs. Progress

With one exception, the idea of shared doctor visits creeps me out, and it's not something I'm likely to take advantage of as long as other choices are available.

First, I'll tell you the one aspect of this idea that does make at least some sense to me: sharing ideas with other patients. From the article:

Wilson, a 52-year-old Littleton man diagnosed with high cholesterol a few years ago, learned a few things at his first group appointment last week. He'd never asked his doctor about drinking red wine before and hadn't known about a diet-assisting website that ranks sugary food on a glycemic index.

Adriana Fischer, a 46-year-old Centennial woman with high cholesterol, said she was thankful other people were there to ask questions — some of which she hadn't thought of on her own. She attended the group visit on her doctor's advice, and because she wanted to know what to do "to prevent any further damage" to her body.

I can see the logic in that. It's almost like a classroom. OK, I get that.

However, I'm a private person, so I'm not really keen on discussing my health matters with others, and overall this strikes me as cheapness disguised as good health care policy.

Ignoring The Costs

Group visits are often sold as part of a new payment paradigm: paying doctors based on performance, rather than services rendered:

Health care reform passed by Congress requires insurance companies to develop plans to reimburse doctors based on performance, not per service. The "medical home" concept is emerging as key to that transformation.

On the face of it, this may seem like a good idea. Who doesn't want better performance for their dollar?

To see one reason why this is a bad idea, simply apply the same principle to something else. Imagine if grocery stores were paid not by the food we take, but by whether that food makes us healthy (this may actually happen someday, if government gets even more involved in food and health). People would take lots of food, there would be shortages, fewer grocery stores, and there would be pressure within grocery stores to present you as being healthy, so they are paid. This in turn would lead to more government oversight of grocers, to make sure they aren't cheating, and so on.

This is exactly what will happen in medicine with the reimbursement by wellness model: shortages, and pressure to overlook actual health problems so the numbers look good and providers can get paid.

Fundamentally, this payment model does not allow insurers to take the actual costs of providing the service into account; it mandates that they provide something regardless of the cost. There is a word for this (hint: starts with "s").

A Shift In Role

Another reason this idea is suspect is that it distorts the nature of what insurance actually is, and more important, whois actually doing the shopping.

Insurance companies are not supposed to shop around and reward good performance, that is our job, when we shop for health care and doctors. Insurers are supposed to pay for the selections we have already made, after the fact. Their job is to reimburse, that's it.

So why is this shift in role from reimbursement to demanding shopper occurring? Because government is not a passive service provider, nor is it an insurer, nor is it a thinking private citizen. It is a pseudo-customer with the power of life and death over the industry, via the powers of licensing, for example. Or via the power to call medical industry executives onto the carpet and read them the riot act, like is happening with the finance industry right now. Their choice is to follow policy recommendations, or have laws rammed down their throats.

What we are seeing is the shift of power away from the public, and into government hands. We are seeing the replacement of individual judgment with bureaucratic judgment, backed by force.

So, let's call shared visits what they are: one more tightening of the noose.

This is the government moving in just a little bit more, making a recommendation here, passing a law there, in its drive for eventual ownership of the medical industry.

When we survey the wreckage our government has made of the industry so far, and consider its "innovative" and "progressive" policy initiatives, let's bear in mind that the general trend of civilization and industrialization has been from the public throng and towards privacy, not the other way around. As wealth has increased, we have been able to afford more elbow room, more privacy, and more of what we as unique individuals want, not what we are forced to have because we cannot afford our own, and must share with the tribe. This includes having private consultations with a physician.

Our medical industry has been so squeezed of funds by government pressure, disruptive taxation and regulation, and being forced to provide services without payment, that we are now reduced to sharing the products we buy. And that is why I cannot see shared doctor visits as a good thing.